transcatheter tricuspid technologies...tricuspid valve "the forgotten valve" in 1967,...
TRANSCRIPT
Transcatheter TricuspidTechnologies
Vinayak (Vinnie Bapat), FRCS.CTh
Assistant Professor of Surgery
Columbia University Medical Center
Tricuspid Valve "The Forgotten Valve"
In 1967, Braunwald et al advised
a conservative approach to TR.
“The present results indicate
that in such patients [functional
TR in patients with mitral valve
disease] tricuspid regurgitation
will improve or disappear after
mitral replacement and that
tricuspid valve replacement is
seldom necessary.”
Braunwald et al. Circulation 1967;35(supplI):63–9
TR cases
Annual New TR
Annual MR Surgeries
Annual TR Surgeries
1,600,000
250,000
50,000
5,500
TR is currently undertreated
Challenges with Tricuspid Regurgitation
• Assessment of symptoms1. Decreased CO – fatigue, decreased exercise tolerance
2. Right Heart Failure – Ascites, LE edema
• Assessment of TR Severity
Diagnostic Challenges with TR
• Regurgitation can be dynamic and very volume dependent
• Volume overload is well-tolerated for years
• Medical and surgical therapies are limited
• Poor understanding about grading the severity of TR on Echo
Extended Grading Scheme
Rebecca T. Hahn, and Jose L. Zamorano. “The Need for a New Tricuspid Regurgitation
Grading Scheme.” European Heart Journal - Cardiovascular Imaging, 2017
Severe Massive Torrential
Surgical Approaches to Tricuspid Regurgitation
De Vega PlastyModified De Vega Plasty
Asa
Ring AnnuloplastysdsdsdsdsdsdsdClover
Kay Plasty
New tricuspid therapies
Mechanism New Technologies
Annuloplasty(Direct and Indirect)
TriAlign Cardioband 4Tech Millepede
Leaflet Devices
Forma MitraClip
Stented Valves in IVC/SVC
Trinity /Sapien NVT
Valve Replacement
Navigate
Approaches:
1. Superior vena cava
2. Inferior vena cava
3. Transapical
4. Transatrial
Annular Devices
Bicuspidization of the TV with the Trialign System
J Am Coll Cardiol 2015;65:1190–5
Severe Isolated Primary Tricuspid Regurgitation
3D EROA3D
Annulus
3D EROA3D
Annulus
Baseline
13.9 cm2
7.6 cm2
(45% reduction)
0.99 cm2
0.43 cm2
(55% reduction)
Post-Trialign
Tricuspid Annular Area (cm2)
p = 0.019
12.3
11.3
10
10.5
11
11.5
12
12.5
Baseline 30 D
∆ 8%
1.02
0.75
0.00
0.20
0.40
0.60
0.80
1.00
Baseline 30 D
p = 0.048
TR Vena Contracta (cm) PISA EROA (cm2)
p = 0.020
0.51
0.32
0
0.1
0.2
0.3
0.4
0.5
Baseline 30 D
∆ 38%∆ 26%
SCOUT 30 Day DataAs-Treated‡*
‡ Change from baseline to 30 days computed on paired data* p-value by paired t-test or Wilcoxon as appropriate
(n=15) (n=15) (n=15)
Edwards Lifesciences Cardioband• Percutaneous band for developed mitral annulus to treat MR• A series of 15-18 anchors implanted in annulus• Performed a series of compassionate use cases in patients with tricuspid
regurgitation
Edwards Cardioband Tricuspid Repair Procedure
1Transfemoral
Approach2
System
Insertion3
Implant
Deployment4
Implant Size
Adjustment
Pre-Reduction Post-Reduction
Bonn University Hospital
Cardioband Tricuspid
Fluoroscopic View
44.4±4(34.8-52.2)
37±5(29.8-45.3)
20
25
30
35
40
45
50
Baseline DischargeSe
pto
late
ral D
iam
ete
r (m
m)
20
25
30
35
40
45
50
55
Baseline Discharge
Sep
tola
tera
l Dia
met
er (
mm
)
*P<0.01
N=26
Edwards TRI-REPAIR Study
17% average reduction in septolateral diameter by core lab
1.3
0.9
Baseline 30 Days
0.8±0.5
0.4±0.3
Baseline 30 Days
PIS
A E
RO
A (
cm2
)
60±20
64.7±12.4
, 64.7
Baseline 30 DaysN=17
Vena Contracta
P<0.001
• Large proportion of patients treated with “torrential TR”
• Improvements resulted in most patients achieving lower severity or
moderate TR at 30 days.
N=20
Ve
na
Co
ntr
acta
(c
m)
PISA EROA
P<0.001
Str
ok
e V
olu
me
(m
l)
LV Stroke Volume
P=0.06
N=18
Edwards TRI-REPAIR Study
50%31%
7%
The 4TECH TriCinch Concept
Hetzer Double Orifice Repair
91 patients with severe TR treated; mean follow- up of 4.1 years
(range 9 months, 19.4 years), no reoperation for recurrent TR
Hetzer R. et al, EJCTS 2013
TriCinch Coil System Procedural Steps
Leaflet Devices
FORMA Tricuspid Valve Therapy System(Edwards Lifesciences)
• Spacer
– Positioned within
regurgitant orifice
– Provides surface for native
leaflets to coapt
– 12, 15 and 18mm sizes
– Advanced from left
subclavian vein
• Rail
– Tracks Spacer into
position
– Anchored at RV apex and
subclavian vein
Case ExampleForma
2.1 ± 1.8
1.1 ± 0.9
1.1 ± 0.6
0.6 ± 0.4
FORMA Early Feasibility StudyEchocardiography Outcomes at 30 Days
(echo core lab)
64 consecutive patients (mean age 76.6±10 years)
Functional TR was present in 88%.
The degree of TR was severe or massive in 88% of patients before the procedure.
The MitraClip device was successfully implanted in the tricuspid valve in 97% of the cases.
Nickenig G et al Circulation. 2017;135:1802–1814.
Mitraclip for Treatment of Severe
Tricuspid Regurgitation
MitraClip For Functional TR
Modeling MitraClip for TR
Vismara, R. et al. J Am Coll Cardiol. 2016;68(10):1024–33.
Spacer is clasped between both Mitral valve leaflets
Independent leaflet clasping system
Simple “commander-like” delivery system
Conventional transfemoral/transseptal approach
Minimal dependence on puncture height
PAddles
Spacer
Clasps
ALfieri
Edwards Pascal Repair System
Caval Implants
J Am Coll Cardiol. 2013;61(18):1929-1931.
Michael Laule, Charité–Universitätsmedizin
Berlin, Campus Mitte, Germany
3 Patients
Sapien XT in IVC and SVC
Sapien in IVC
Sapien in IVC
What if the IVC is >30mm
Z stent used as scaffold
29mm S3 deployed with contrast injection to guide positioning
Sapien in IVC
Sapien in IVC
Sapien in IVC
Large IVC >35mm
External Ring to downsize IVC
Sapien 29 through Femoral Vein
Transcatheter Tricuspid Valve Replacement
Navigate Transcatheter
Valve
VALVED-STENT DIMENSIONS (mm)
Ventricular Ø
36 40 44 48 52
Atrial Ø
30 30 33 36 38
HEIGHT
20 18.2 19.4 22 21.4
• Presently 35F distal capsule OD
• 24F catheter shaft
• 80° Articulation
• Controlled Valve Release
• All modes of delivery use the same valve configuration
NAVIGATEValved Stent Delivery System
60
Surgical Access
• Right thoracotomy
• Right diaphragm retracted down to expose the site of the pure string
Valve release
Intra-procedural TEE –valve deployed
Right ventriculography post valve deployment
What has the early experience demonstrated?
• Patients often present with torrential TR
• Procedures are relatively safe
• ~50% reduction in EROA
• Improvement in clinical symptoms
• Durability is unclear
Next Steps
• Tricuspid Regurgitation Classification
• TR evaluation
• Understanding RV reserve
• Therapy in presence of PPM
• Repair vs Replacement